Provider Demographics
NPI:1255607578
Name:RILEY, MATILDA L
Entity type:Individual
Prefix:MS
First Name:MATILDA
Middle Name:L
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 DR MARY MCLEOD BETHUNE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3602
Mailing Address - Country:US
Mailing Address - Phone:386-323-9855
Mailing Address - Fax:386-253-2335
Practice Address - Street 1:875 DR MARY MCLEOD BETHUNE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3602
Practice Address - Country:US
Practice Address - Phone:386-323-9855
Practice Address - Fax:386-253-2335
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker